Breakdown

Abstract

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. A 47-year-old paraplegic man presented to our emergency department (ED) with severe pain from his sacral decubitus ulcers. Earlier that day, he had left against medical advice from another area ED. He took no medications but noted that he had been on several medications during recent hospitalizations. He had smoked cocaine that morning. He reported 3 days of watery diarrhea. His triage temperature was 98.28F, his heart rate was 146 beats per minute, and his blood pressure was 155/84 mm Hg. He had multiple foul-smelling, stage 4 sacral ulcers and a chronic indwelling urinary catheter. Laboratory results included: white blood cell (WBC) count 22,000/ mm 3 (neutrophils 17,900/mm 3 ), hemoglobin 8.5 g/dL, platelet count 317,000/mm 3 , creatinine 4.2 mg/dL, and lactate 1.5 mg/dL.